Workshop on Deconstructing Back Pain: Agenda

Goals

To identify what types of future studies are needed to better understand chronic back pain

To assess new interventions and management strategies for back pain as a chronic condition

To evaluate the utility of existing datasets and ongoing cohort studies for future studies of chronic back pain

To determine what study designs should be utilized to look at the natural history of back pain

Format: Each session will focus on how a given theme informs what types of future studies are needed. The session chair will give a broad overview of the goals for that session, and introduce the presenter and discussant. The presenter will provide focused background information about the identified research topic and highlight key research questions to seed the general discussion. The discussant will provide additional comments on the presentation, and insights into what strategies and future studies are needed to move the field forward.

What is known about chronic back pain? How much of back pain is truly due to a chronic neuro-musculoskeletal disorder versus central CNS mechanisms (e.g., central sensitization) or latent psychological traits (catastrophizing, somatization)? What are the key knowledge gaps, and what types of studies needed to move the field forward? What types of existing data sets (retrospective cohort studies) are available and how could they be utilized?

Studies needed to develop a research characterization system for chronic back pain
Session chair: Rick Deyo, M.D., Oregon Health and Science University

For the majority of back pain patients, the precise etiology of their condition is poorly, if at all, understood. Consequently, various characterization paradigms/systems have been developed by different clinical disciplines/professions. This session will explore whether the use of a common lexicon would facilitate research on chronic back pain. How could such a lexicon be developed if it is not currently available? What existing resources (data sets) are available to achieve this goal? What types of new studies are needed to refine current characterization systems of chronic back pain?

Epidemiology of the natural history of chronic back pain: gaps, and opportunities
Session chair: Gary Curhan, M.D., Sc.D., Harvard Medical School

Chronic back pain, rather than being a stable or unchangeable condition, is now thought to be characterized by significant variation in symptoms and/or functional status. What is the “natural history” of chronic back pain? What existing resources/datasets are available to carry out natural history studies? Does chronic back pain manifest differently depending on age, race, ethnicity, gender? Do events/injuries early in life have long-term consequences on the development of chronic back pain? Would retrospective cohort studies be appropriate to answer these questions? Could prospective studies be used, and if so, what kind of studies would be optimal?

What are the utilization treatment patterns of chronic back pain patients and does this affect outcomes? Are surgical therapies utilized effectively for patients that will benefit? Are combination therapies (e.g., pharmacological + non-pharmacological interventions) or integrated management utilized more or less than mono-therapies? How much is self-care versus practitioner-guided care? How do age, gender, race, ethnicity, as well as severity of condition affect utilization? What can we learn from geographic variation? What types of studies are needed to best answer these questions? Are there existing datasets (including claims data) that would facilitate research in this arena? What types of prospective studies may be needed?

1:45 p.m.

Presenter: Tim Carey, M.D., University of North Carolina

1:55 p.m.

Discussant: Simon Dagenais, D.C., Ph.D., University of Ottawa

2 p.m.

General discussion

2:50 p.m.

Break

3:05 p.m.

Psychological components of chronic back pain
Session chair: Robert Gatchel, Ph.D., University of Texas at Arlington

Many chronic back pain patients are likely to exhibit psychological traits of catastrophizing and somatization. Moreover, there is high incidence of depression in that population. Biopsychosocial models for chronic back pain (cf. Weiner 2008) posit that “… medical co-morbidities, illness beliefs, coping strategies, emotional reactions, fear and depression, employment, and economic concerns …” are important, if not dominant, factors in chronic back pain. What studies are needed to further elucidate the role of these factors in treatment and management of chronic back patients? Are there existing datasets that would be useful in such studies? Would combinations of interventions (e.g., NPI + counseling) be more effective than mono-therapies? How can the biopsychosocial research data be translated into existing treatment paradigms to optimize treatment and long-term management?

3:10 p.m.

Presenter: Dennis Turk, Ph.D., University of Washington

3:20 p.m.

Discussant: Robert Kerns, Ph.D., VA Connecticut Healthcare System

3:25 p.m.

General discussion

4:30 p.m.

End Day 1

Day 2:

There is broad agreement that there is a critical need for validated biomarkers of chronic back pain in order to advance research in this field. However, developing such biomarkers has proven to be an enormous challenge. What are the most promising areas that should be pursued? Are these areas relevant to non-pharmacological interventions including CAM interventions? Are there existing datasets or cohort studies that are currently of relevance to this area? Are there existing human and/or animal models of chronic back pain that could be utilized, and if so, then in what fashion?

Are current outcome measures adequate? How consistent are measures focused on minimal clinical important difference, or minimal important difference [MID]? How much change is truly important? What is the impact of patient expectation on these measures? What do we gain by adopting a new measure of sufficiently important difference (SID) in clinical studies (cf. Barrett et al., 2005)? Are existing datasets available that would enable re-assessing outcomes based on SID? Are there other more sophisticated or meaningful measures? Should a consensus statement of necessary and sufficient outcome measures be developed for future clinical trials of interventions for chronic back pain?